Your Partner in Person-Centered Care

SeniorServ Care Coordination Services

SeniorServ Care Coordination is a comprehensive “advocate” service for partner organizations to reduce hospital admissions, readmissions and ED visits; and to provide complex case management services for person-centered care solutions.

SeniorServ partners with healthcare plans, hospitals, senior housing, and other organizations who need a consistent and on-going plan of care and communication system to reduce escalation of health issues, reduce confusion regarding care, and reduce stress on families by increasing information sharing.

Our Care Coordination program provides Meals on Wheels five days a week, and daily visits by our care manager who assists with chronic disease management, medical appointments, access to health care, access to mental health group therapy, and legal assistance.

Actual interaction with the client in their home – performing a full client assessment and creating a comprehensive, on-going plan of care, which will then be communicated to the client, family/caregiver and physician and adjusted as needs change

Cost control for any provider of that care; i.e., Managed Care Organizations, IPA, ACO, etc.

Reduction in Readmission – for both hospitals and Skilled Nursing Facilities

Reduction of ED visits

Reduction of 911 calls due to unmanaged or mismanaged health issues for the elderly, including disease, depression and abuse

Short term case management/nutrition for persons under 60 discharged from Rehab facilities